Student Application v2

Need a form to register to a Summer Institute? This form collects your personal contacts, school information and personal motivation. It includes a subject interests ratting scale.

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Tags: registration,application,summer institute
Shared by: allstarcode

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Student Application v2 Form Template | JotForm

I. Introduction (Directions)

Welcome to the application for All Star Code’s 2014 Summer Institute! Please complete the following application and submit it no later than 11:59pm (EST) on April 3, 2014. We estimate that it will take you 1-2 hours to complete. Please complete all questions thoughtfully and with care. Your responses will form the basis of All Star Code’s impression of you, and will be the initial determinant of your selection into our program. In short, your path into our program begins here! Your application is saved automatically every 30 secs. You can return from the same browser at any time within 30 days and complete it prior to the deadline. Thank you very much. And good luck!
II. Application Information
Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
E-mail *
Gender *

Male Female
Languages Spoken *
Ethnicity *

American Indian Asian American Black/African American Mexican American Puerto Rican Other Latino White Other
Race/Ethnicity Additional Detail (optional)
Date of Birth *

Month Day Year
Free/Reduced Lunch or Financial Aid? *

Free/Reduced Lunch Financial Aid Both None
Do you have a computer at home? *

Yes No
III. Parent/Guardian Information (e.g., parent, grandparent, guardian, etc.)
Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Languages Spoken *
Home Phone *

- Area Code Phone Number
Cell Phone *

- Area Code Phone Number
E-mail *
Additional Parent/Guardian (Optional)
Full Name

First Name Last Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Languages Spoken
Home Phone

- Area Code Phone Number
Cell Phone

- Area Code Phone Number
E-mail
IV. Emergency Contact Information
Contact Name *

First Name Last Name
Relationship *
Phone Number *

- Area Code Phone Number
V. School information
Do you attend any of the following schools? *

Eagle Academy II Academy for Software Engineering Other
If not, complete below.
School Name

School Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Current GPA *
Current Year in School *

Freshman Sophmore Junior Senior
Are you currently enrolled in a free or reduced lunch program? *

Yes No
Does your school offer Computer Science courses? *

Yes No
If so, have you taken (or are currently taking) this class?

Yes No
And if so, what is the name of the Computer Science teacher? (Please list name(s) here.)
VI. Teacher Reference
Full Name *

First Name Last Name
Subject Taught *
Phone Number *

- Area Code Phone Number
E-mail *
Best time to contact this reference? *
VII. Adult Reference (Not a parent or guardian)
Full Name *

First Name Last Name
Relationship *
Phone Number *

- Area Code Phone Number
E-mail *
Best time to contact this reference? *
VIII. Notice of Commitment

I understand that, if accepted, I must commit to being an active and engaged participant in All Star Code’s Summer Institute for the duration of the 6-week program. This includes attendance Monday through Friday, 9am – 5pm. I must also make the most of the program by completing high quality coding projects, working well with fellow All Stars, learning from mentors, and getting the most from guest speakers and tech company field trips. I also agree to represent All Star Code to the best of my ability, displaying my talent, drive, persistence, and professionalism at all times, and to all guests.
*

I Accept
IX. About You
What work would you like to be doing when you graduate from high school or from college? What types of jobs do you find interesting? *
What are your favorite things to learn about or do, both inside and out of school? Give examples, explaining why these things interest you. (Discussing one interest is fine). *
What did you do last summer that was important to you? (It could be a job, trip, camp, hobby, or anything else.) Briefly explain. *
What is a problem in the world (big or small) that you think would be best solved using technology? Tell us about it briefly. *
How did you hear about All Star Code? Please be specific and list any individual, organization, program, school or other medium. *
X. Interests

Rate your interest level in the following subjects. (1= Not At All, 5=Very Interested)
High School Subjects

Math *

	1	2	3	4	5
Not At All						Very Interested

Science *

	1	2	3	4	5
Not At All						Very Interested

Computer Science *

	1	2	3	4	5
Not At All						Very Interested

English *

	1	2	3	4	5
Not At All						Very Interested

History *

	1	2	3	4	5
Not At All						Very Interested

Philosophy *

	1	2	3	4	5
Not At All						Very Interested

Theatre *

	1	2	3	4	5
Not At All						Very Interested

Debate *

	1	2	3	4	5
Not At All						Very Interested

Technology-Related

Coding/Programming *

	1	2	3	4	5
Not At All						Very Interested

Phone Apps *

	1	2	3	4	5
Not At All						Very Interested

Mobile Technology *

	1	2	3	4	5
Not At All						Very Interested

Video Gaming *

	1	2	3	4	5
Not At All						Very Interested

Robotics *

	1	2	3	4	5
Not At All						Very Interested

Other Cool Things

Business/Entrepreneurship *

	1	2	3	4	5
Not At All						Very Interested

Sports *

	1	2	3	4	5
Not At All						Very Interested

Music *

	1	2	3	4	5
Not At All						Very Interested

Movies *

	1	2	3	4	5
Not At All						Very Interested

If you have accounts with any of the following services, can you provide us with your username or profile URL? (This is optional -- we don’t have an expectation that you have an online profile. But if you do, it may help us get to know you better.)
Twitter
Instagram
Facebook
YouTube
Tumblr
Github
Snapchat
Other
XI. Personal Statement
1. Tell us why you are interested in participating in All Star Code’s Summer Institute? What would you hope to get out of this experience? *
2. Has there been a mentor/teacher who has been important to you? What are your favorite things about this person? *
3. Is there anything about technology that really excites you? *
4. What would you say are your two greatest skills or talents? (These can be “technical” or “soft” skills. For example, “technical” skill could be drawing, writing, reading a lot, building models, etc. “Soft” skills could mean leading groups, making friends easily, understanding people, etc. ). *
5. What skill – either “technical” or “soft” – would you like to work on? Why? *
6. Is there anything else about yourself that you would like to share? We would be interested to know! *
7. (Optional) Vision Drawing. Draw a picture of your world, as you wish it to be, 30 years from now. Draw it however you wish. Use color only if you want. And use whatever means you desire to create the picture. How you create it is up to you!
XII. Answer the Questions Below
1. Which figures completes the series?
*

A B C D
2. Number Sequence

What number should replace the question mark?

0, 19, 38, 57, ?, 95
*
3. Find the Solution

The Frog

A frog is at the bottom of a 30 meter well. Each day he summons enough energy for one 3 meter leap up the well. Exhausted, he then hangs there for the rest of the day. At night, while he is asleep, he slips 2 meters backwards. How many days does it take him to escape from the well?

Note: Assume after the first leap that his hind legs are exactly three meters up the well. His hind legs must clear the well for him to escape.
*
4. Reading Comprehension

Directions: Read the passage. Then answer the questions below.

The Incredible Machine

Everyone has a favorite attraction at an amusement park, and I am no different. However, unlike most people who seem to prefer roller coasters, my favorite ride is a little gentler. Every time I go to Coney Island, Navy Pier, or the Santa Monica Pier, I absolutely have to ride the Ferris wheel. The Ferris wheel is simple and yet also quite complex. That is, riding it is easy, but how it works is complicated. A series of carts are attached to a wheel, which is attached to a rim. That rim rotates vertically around an axis, and gravity keeps the carts upright. As simple as the ride seems, only advanced engineers can make safe and fun Ferris wheels.
1. As used in paragraph 1, the word attraction most nearly means *

sense park ride vision
2. It can be understood that Coney Island, Navy Pier, and the Santa Monica Pier are all examples of *

amusement parks Ferris wheels vacation spots boat docks
3. As used in the paragraph, which is the best antonym for complex? *

impressive beautiful exciting simple
Should be Empty:

Student Application v2

I. Introduction (Directions)

II. Application Information

III. Parent/Guardian Information (e.g., parent, grandparent, guardian, etc.)

IV. Emergency Contact Information

V. School information

VI. Teacher Reference

VII. Adult Reference (Not a parent or guardian)

VIII. Notice of Commitment

IX. About You

X. Interests

XI. Personal Statement

XII. Answer the Questions Below